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PHS/OlAUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION• <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: / /,tomBY: REVIEWED BY: DATE ENTERED: 1j BY: <br /> SWEEPS/SITE CODE � PROGRAM/ELEMENT Z� `D COMP # LOC CODE DIST # <br /> LOT FILE PILOT FILE H W FILE SITE 111TIGAT ION PUS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT I L' () DHS CONTACT <br /> OTHER CONTACT RWOCB CONTACT WDR issued Y / N NPDES issued Y / N <br /> FAILED PT SOIL CONT GW CONT DW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 #2 #3 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> EIIFORCEMENT TYPE:: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS <br /> CITY �C r ,q.� ,a,_,� STATE �//,� ZIP <br /> CONTACT NAME J t.--' I µms '`+ PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME � �7(-f�- CGE PHONE <br /> CONTACT NAME ✓✓✓ PHONE <br /> ADDRESS 22JJD- YOSEfitt LE . <br /> CITY cf,o-, 1 STATE 21P 5 2 <br /> RESPONSIBLE PARTY (If diff{erlen`tVf/r\o-m/Property Owner) J <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP / <br /> CONSULTANT l�i PHONE <br /> 1UAR # DATE PROP 65 # DATE PRIORITY <br /> STREET # SITE STREET Ft-tLkIR APN # <br /> EH 23 070 (7/89)REVISEED 03/91 89-19(IV) CNTMFR2 <br />